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Patients’ resuscitation status in community hospitals | Signal

Reference number
Issue date14 February 2011

This Signals item is about confusion relating to patients’ resuscitation status in community hospitals, and subsequent risk of harm. 

A search of the National Reporting and Learning Service (NRLS) database identified 15 incidents during a 12 month period where confusion about resuscitation status could have caused harm.  The incident reports highlight the potential of confusion to cause:

• delays in attempting resuscitation in patients who might be able to recover from cardiac and respiratory arrest with prompt intervention;
• inappropriate resuscitation of patients who have naturally reached the end of their life: leading to the possible pain, distress and an undignified death.

A sample incident report reads:

“…Pt did not have a Do Not Resuscitate order in place. However night staff on duty failed to instigate CPR or place Crash Call as per policy / procedure in these instances…”

All community hospitals may wish to ensure that:

• A resuscitation status policy is in place that reflects the requirements of the Mental Capacity Act 2005 as well as current best practice guidance (such as that issued by the Resuscitation Council UK) on decision making in resuscitation and end of life care. The policy should require the use of a format to structure and record decisions made in relation to resuscitation.
• Nursing and medical staff implementing the policy are supported through training and regular updates to acquire and maintain the competence to support patients (and their families and surrogates) in decision making in relation to resuscitation. 

The incidents reported to the NRLS suggested more thought may need to be given to practical considerations of implementing such policies. For example:

• Should resuscitation status decisions made in an acute trust (before the patient is transferred to a community hospital) continue to be treated as valid?
• Are the medical staff and senior nursing staff available on frequent enough basis for decisions to be made early in the patient’s care pathway?

Local audit is an important tool to identify any practical challenges to ensuring compliance with resuscitation status policy and that all nursing and medical staff have the skills and confidence to implement it.

Please contact us with your initiatives to reduce risk in this area.

Signals are notifications of key risks emerging from review of serious incidents reported to the NRLS and shared by the NPSA.